Pathology/Lab Coding Alert

Question: The pathologist received a breast tissue specimen that the surgeon labeled, “breast margin re-excision.” Three weeks prior, the surgeon had submitted a lumpectomy specimen from the same patient, which the pathologist had diagnosed as invasive ductal carcinoma, proximal margin not clear. For the new specimen, the pathologist again diagnosed invasive ductal carcinoma, but this time the margins were clear. What should we consider this specimen, and what procedure code would be appropriate for the pathologist’s work? Does the pathologist’s diagnosis impact the procedure code choice?

Maryland Subscriber

Answer: Because the pathologist documented examining the breast tissue specimen margins for a second time, the appropriate procedure code is 88307 (Level V - Surgical pathology, gross and microscopic examination; … Breast, excision of lesion, requiring microscopic evaluation of surgical margins…).

Code 88307 is appropriate in this case whether or not the pathologist diagnosed cancer in the specimen. The key is that the pathology exam required a surgical margin exam, because the specimen was a re-excision to check for clear margins and ensure there was no remaining cancer.

Avoid: You should not list this breast specimen as 88305 (Level IV, Surgical pathology, gross and microscopic examination; … Breast, biopsy, not requiring microscopic evaluation of surgical margins … Breast, reduction mammoplasty …), as the descriptor for this procedure states it does not require microscopic evaluation of surgical margins. You should also not use 88309 (Level VI, Surgical pathology, gross and microscopic examination; … Breast, mastectomy - with regional lymph nodes…). Even though this

descriptor does note the procedure requires microscopic evaluation of surgical margins, the breast tissue obtained is from a breast mastectomy, which is not the sample the pathologist received for either of the evaluations.